Deceased
Laurence Bishop
Demographics
84y, male
Date of death
2019-06-23
Finding date
2020-06-12
Cause of death
aspiration pneumonia following advanced multifactorial dementia
AI-generated summary
Laurence Bishop, an 84-year-old man with advanced multifactorial dementia (Alzheimer's and vascular dementia), died of aspiration pneumonia at a specialised aged care facility. He had been admitted to the Roy Fagan Centre following progressive cognitive decline requiring full-time care. One month before death, he was transitioned to palliative care with medication reduction due to dysphagia. He developed loss of swallow reflex and died peacefully in the facility. Autopsy confirmed aspiration pneumonia with evidence of significant cerebrovascular disease. The coroner found care was of a high standard in difficult circumstances. No clinical errors or preventable factors were identified. This case illustrates appropriate end-of-life management and recognition of inevitable decline in advanced dementia.
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Specialties
Drugs involved
FINDINGS of Coroner Simon Cooper following the holding of an inquest under the Coroners Act 1995 into the death of:
Contents
Record of Investigation into Death (With Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Simon Cooper, Coroner, having investigated the death of Laurence Bishop with an inquest held at Hobart in Tasmania make the following findings.
Hearing Dates 5 June 2020 Representation Counsel Assisting the Coroner: J Ansell I find pursuant to Section 28(1) of the Coroners Act 1995 that: a) The identity of the deceased is Laurence Bishop; b) Mr Bishop died in the circumstances set out below; c) The cause of Mr Bishop’s death was aspiration pneumonia following advanced multifactorial dementia; and d) Mr Bishop died on 23 June 2019 at the Roy Fagan Centre, Lenah Valley, Tasmania.
Background
Health
In 2014, Mr Bishop was diagnosed with Alzheimer’s disease and vascular dementia.
Over the following years, Mr Bishop’s health steadily declined. He was diagnosed with Wernicke’s Dysphasia1 and suffered anxiety, confusion and pathological crying. Mr Bishop was 1 The inability to understand the written or spoken word, see exhibit C9, page 22 of 28.
treated with antidepressant medication. In 2015, he suffered a stroke. His health deteriorated to such an extent that he required ongoing full-time care.
In July 2018, Mr Bishop began living at the Bishop Davies Nursing Home in Kingston. He stayed there until November of that year. A further deterioration in his condition meant that it was necessary for him to be relocated and ultimately, on 14 December 2018, he began to reside at the Roy Fagan Centre (RFC). The RFC is a specialised hospital dedicated to the care of older people suffering from either cognitive impairment or psychiatric illness.
Upon admission to the RFC Mr Bishop was diagnosed as suffering from advanced dementia.
He remained at the RFC, under treatment, for a period of 191 days until he died.
Doctors reduced the amount of medication he was taking as he was losing his ability to swallow.
Circumstances of Death
On Wednesday 19 June 2019, Mr Bishop began to gurgle and nursing staff noticed he was losing his swallow reflex.
On Saturday 22 June 2019, Mr Bishop was not given any medication as he was unable to swallow, and was expected to pass away that day. Nurses noticed his legs were going blue and getting cold.
Around 3.00am on Sunday 23 June 2019, Mr Bishop was bathed. He was last seen alive at 6.30am, and found dead approximately 10 minutes later.
Investigation
Dr Ritchey expressed the opinion3, which I accept, that the cause of Mr Bishop’s death was aspiration pneumonia complicating advanced multifactorial dementia. At autopsy, he found marked cerebrovascular disease and multiple remote brain infarcts (strokes).
2 See exhibits C3 and C4.
3 Affidavit of Donald MacGillivray Ritchey sworn 25 July 2019 page 9 of 11, exhibit C5.
There was no evidence of violent injury identified at autopsy. Specifically, no scalp contusions, skull fractures or intracranial collections of blood were found and Mr Bishop had no injuries of the chest or abdominal walls.
Mr Bishop’s medical records were obtained and reviewed. The care afforded to Mr Bishop was reviewed by the Medical Advisor to the Coronial Division, Dr Anthony J Bell. Dr Bell expressed the opinion, which I accept, that the care Mr Bishop received at the RFC was of a high standard, in a difficult situation.
Conclusion
I am satisfied on the evidence that Mr Bishop was appropriately cared for whilst at the RFC and received a high standard of medical care. In the circumstances, there is no need for me to make any comments or recommendations.
In concluding, I convey my sincere condolences to the family of Mr Bishop.
Dated: Friday 12 June 2020 at Hobart in the State of Tasmania.
Simon Cooper Coroner
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